Health Sciences Center Library, Kuwait University

Psychiatric Consequences of HIV Infection

The mental disorders seen in people with HIV infection are similar to those that occur in individuals suffering from other potentially fatal conditions that have an unpredictable course. They include a range of normal psychological reactions (such as shock, denial and distress), as well as abnormal responses (such as suicidal behaviour and major depression). There are, however, differences in comparison with other disorders, due to features specific to HIV infection:

Brain-related complications of HIV can give rise to organic psychiatric disorders, including dementia.

Individuals with HIV infection are at increased risk of developing mental health problems (there is often a history of psychological and social difficulties prior to acquiring HIV).

The social stigma associated with HIV and AIDS often adds to the problems faced by those trying to adjust to the physical consequences of the condition.

Identification of factors associated with the development of significant psychiatric morbidity should help in recognising those at risk and in providing effective interventions. Such factors include:

HIV-related factors - notification of HIV infection, decline in health, AIDS diagnosis, disfiguring or disabling symptoms.
History of psychiatric problems.
Lack of social supports.
Avoidance and denial as a habitual way of coping.
Exposure to grief due to AIDS, and other adverse life events.
Personal characteristics: older age, reduced 'brain reserve', ethnicity and gender, historical/current injecting drug use.

People with HIV infection can develop a wide range of mental disorders:

Abnormal psychological reactions - adjustment disorders, manifestations of personality disorder.

Mood and other disorders - major depression and other depressive syndromes, suicidal behaviour, manic episodes, sexual dysfunction, anxiety disorders, obsessive compulsive disorder, eating disorders, association with child sexual abuse.

Organic brain syndromes - acute and sub-acute brain syndromes, HIV-associated dementia, HIV-associated minor cognitive impairment.

Abnormal psychological reactions

Symptoms of anxiety, insomnia and depression, as well as social impairment, are common in response to the discovery of HIV infection or the development of complications. Whilst usually mild and self-limiting they can be severe and disabling.

Adjustment disorder is one of the most common diagnoses in people referred to mental health services (~30%) whilst personality disorder is often an associated diagnosis (usually avoidant, dependent, narcissistic or histrionic features, sometimes made worse by substance misuse).

Mood and other disorders

Suicidal ideas are common in people with HIV, and there is a risk of both deliberate self-harm and suicide.

Severe depression has been reported in about 15% of referrals to mental health specialists.

The risk of manic episodes seems to be increased in HIV, mania being the most frequent reason for psychiatric hospitalisation among people with HIV. In some cases, illicit drug use or iatrogenic causes are implicated, as can be the chance association of HIV infection and bipolar affective disorder, but in the majority of cases no obvious aetiological factors are identified. Most cases of new-onset mania occur in advanced HIV disease and they are often associated with the presence of substantial cognitive impairment. New-onset mania in severe symptomatic disease is predictive of reduced survival.

Sexual dysfunction is common in HIV, organic and iatrogenic factors being important in advanced disease stages. Anxiety disorders, including phobias and panic attacks, and obsessive-compulsive disorders are occasionally seen.

Eating disorders can complicate the management of HIV.

Organic brain syndromes

Neuropsychiatric syndromes are common in HIV infection. Immune suppression can lead to a variety of secondary complications affecting the brain, including opportunistic infections such as cerebral toxoplasmosis and progressive multi focal leucoencephalopathy, and tumours such as cerebra lymphoma.

Acute and sub-acute syndromes (delirium) often occur as a result of systemic disorder and secondary infections. However, even in the absence of secondary complications, HIV infection can be associated with adverse effects on brain function.

Primary HIV-related brain disorders include HIV-associated dementia and minor cognitive disorder.

HIV-associated dementia

This is characterised by substantial memory and intellectual decline, with often marked psychomotor slowing, and the possible presence of motor abnormalities, in the absence of delirium or secondary HIV-related disorders.

Recent reports suggest a prevalence of up to 15% in advanced disease.

Dementia tends to develop over a relatively short period of time, and once present it is associated with poor prognosis (as a rule, dementia is a syndrome of the final year of life, although on occasion it can develop earlier).

HIV-associated minor cognitive disorder

This develops mostly in symptomatic patients whether or not they have a diagnosis of AIDS.

Clinical features include poor memory and attention, slowed information processing and difficulty with abstract thinking.

While 5% of newly diagnosed AIDS cases have been found to be impaired, the proportion increases to 60% in late AIDS.

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